Laserfiche WebLink
FOR OFFICE USE: PLICATION FOR WELL OR PUMP PERMIT PERMIT N0. S3 <br /> ((( (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> JOB ADDRESS/LOCATION: _/V�?,epF _A ,V gf,,1✓ ,...�3�,/ CENSUS TRACT: <br /> OWNER'S NAME: L PHONE: _. <br /> ADDRESS: <br /> -- j 4_�'f.7 A/ hlV,-?. __A40j e 4, � ,"fibt�`CITY: � .�rcr <br /> CONTRACTOR'S NAME: 7-7-e, LICENSE # PHONE: „ . <br /> �r3 S°- � �e•r <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /PUBLIC WATER WELL / / TEST WELL <br /> ~IRRIGATION/LIVESTOCK/AGRICULTURAL _WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / f GEOPHYSICAL WELL / / OTHER /_7 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS., TYPE OF REPAIRS: pG' ca ►! /A.ff. & ,s j.4 <br /> 4 <br /> -i1 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> C <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARZ4ENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: Z//,7 <br /> ADDITIONAL COMMENTS: f <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: � DATE 3 - 20 -7Z-- <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT_ 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />